Transcription

1 *NOTICE * THIS APPLICATION WAS REVISED IN JUNE 2015 PLEASE READ CAREFULLY Change of Ownership License Application To Operate an Abortion or Reproductive Health Center Regulations affecting the application for licensure of Abortion or Reproductive Health Centers can be found by clicking the Rules tab or link on the applications page. The application should be submitted to this office at least 30 days prior to the change of ownership. In addition to the information requested within the application, the following must also be submitted: 1. A completed license application and $200 application fee. Application fees are not refundable. 2. Organizational documents such as Articles of Incorporation, Partnership Agreement, LLC Agreement, or Statement of Sole Proprietorship under which the facility will operate. A copy of the registration to conduct business in Alabama must accompany this application, if the entity was established in a state other than Alabama. 3. A copy of the document consummating the transfer of ownership, such as a lease agreement, sales agreement, or management agreement. An unsigned copy or draft is acceptable with the submittal of this application. However, a signed copy must be submitted prior to the issuance of a license certificate. Upon successful review of the application, a copy of the application will be forwarded to the Division of Health Care Facilities. A staff member from the unit will contact you regarding an on-site licensure visit to determine if the facility meets minimum requirements for a state license. *NOTE* Due to workload volume, application review takes a minimum of thirty days. An on-site survey (if required) could add considerable time to completion of the licensure process. Applications must be submitted well in advance of anticipated start of operations. Applications must be submitted with all required documents and certificates as noted in the instructions before the review can begin. Abortion or Reproductive Health Center 1 Page

2 You are welcome to contact the department for ways to expedite the application process to shorten the review time. The earliest date a license can be granted is the first day the complete application and any surveys have been approved by the Department. [For certified health care facilities and agencies, application to the appropriate MAC is recommended 180 days in advance of the anticipated start of operations.] For state licensure purposes, a change of ownership is not effective until a new license has been granted. Printing of License Certificates License certificates are now available on-line. When a license is granted or renewed the license certificate can be printed on-line at A facility ID and pin number will be provided and must be used to print license certificates. Please note: it is a violation of state law to operate as an abortion center before you are granted a license from this agency. If you have questions regarding your application, please call (334) Abortion or Reproductive Health Center 2 Page

3 ADDITIONAL INFORMATION ABORTION OR REPRODUCTIVE HEALTH CENTER Item 1, Applicant. The applicant is the individual, partnership, corporation or other entity who will be the governing authority of the facility and to whom the license will be granted (not the facility name or the individual completing the application, unless the applicant is an individual). The name entered in this section must be exactly as printed on the legal document establishing the entity. A copy of the legal document must accompany this application. Entities established in a state other than Alabama must register to conduct business in Alabama with the Secretary of State s Office. A copy of the registration must also accompany this application. If the facility is leased, the lessee should be indicated as the applicant. The lessee may be an individual, partnership, corporation, or other entity. NOTE - The applicant must be the operator of the facility, the entity that hires or fires the administrator, determines patient care issues, makes payment for facility obligations, etc. Item 6, Facility Name. The information provided on this line will be entered in the Provider Services Directory and the facility will be referred to by this name exactly as entered on this application. This name should be the same as on advertisements, facility letterhead, signs in front of the facility and certification information. This name must be unique; that is, it may not be the same as the name of any other licensed facility in Alabama, nor may it be so similar to the name of any other licensed facility that, in the judgment of ADPH staff, there could be any confusion to the public. Governing authorities operating more than one facility may give the facilities they operate similar, but not identical names. The name may be abbreviated if the abbreviation is also used on advertisements, facility letterhead, signs in front of the facility and certification information. Item 8, Facility Mailing Address. The facility mailing address, street address or post office box must be within the same postal service area as the facility s physical location. Item 18, Attestation of Responsible Person. A company officer, board member, administrator or other responsible person must sign the application and make the attestation. Application Fee. The application fee for an abortion or reproductive health center is $200. Application fees are not refundable. Make a check or money order payable to the Alabama Department of Public Health. Attachments. Each attachment must be referenced as a specific applicable item. For example, attachment to item 13 d should be referenced in the document and labeled as such. Abortion or Reproductive Health Center 3 Page

5 13. Applicant Information a. Applicant is a (check one): Individual Nonprofit Corporation City Partnership Hospital Authority County Corporation State Joint City County Limited Liability Company Other: Specify b. List all the applicant s board members and officers (attach additional paper if necessary). c. List the name(s) of any person or business entity that has 5% or more ownership interest in the applicant (attach additional paper if necessary). Also, attach a diagram depicting the organizational structure. d. Does this applicant or any of its owners listed in item c operate any other health care facility in Alabama or in any other state? YES NO If yes, attach a list including the type(s) of facility(s), name(s), address(s), and owner(s). e. Have any of the facilities listed in item d had any adverse licensure action taken against them or been subject to exclusion from the Medicare or Medicaid Reimbursement Programs? YES NO If yes, attach an explanation. f. Have the applicant, officers or principals ever had a license application denied by this or any other state? YES NO If yes, attach an explanation. Abortion or Reproductive Health Center Page 5

6 14. Has the facility administrator listed in item 5" of this application: a. ever been convicted of a crime? YES NO b. ever been found guilty of abusing another individual? YES NO c. ever had adverse action taken against a professional license, for example, nursing home administrator license, attorney license, nurse license, physician license? YES NO d. ever been excluded from participation in Medicare or Medicaid Reimbursement Program? YES NO If a, b, c, or d are yes, attach an explanation for each affirmative answer. 15. Are there any outstanding citations of deficiency, either Federal or State, that have not been corrected? YES NO If yes, has the plan of correction for these deficiencies been accepted by the Division of Health Care Facilities? YES NO Note: The new operator will be responsible for correcting all outstanding deficiencies and may be subject to sanctions imposed for past or present deficiencies, including payment of any uncollected civil monetary penalties. 16. Provide the name, phone number, and address of a knowledgeable person who can supply details about this application. Name (print) Title Address City-State-Zip Phone Abortion or Reproductive Health Center Page 6

7 17. Administrator Signature: I declare, under penalty of perjury, that I have not operated or allowed to be operated this facility, or any other facility, without a license. I agree to operate this facility according to the Rules of the Alabama State Board of Health. Printed Name Signature Date NOTARIZED: Sworn to and subscribed before me this day of Attestation of Responsible Person: (Notary Public) I declare, under penalty of perjury, that I have personal knowledge about the statements made in this application and certify that all statements are true and correct. To the best of my knowledge, neither the applicant nor any of the principals, including myself, the owners, and the administrator have operated or allowed to be operated this facility, or any other facility, without a license. I certify that I am authorized to make this representation on behalf of the applicant. Signature: _ Print: Name Title/Position: Date: NOTARIZED: Sworn to and subscribed before me this day of 20. (Notary Public) Abortion or Reproductive Health Center Page 7

8 19. Current Licensee s Signature The current licensee of this facility concurs with this change of ownership and recommends that this change of ownership application be granted. I certify that I am authorized to make this representation on behalf of the current licensee. Name of Current Licensed Entity Signature Date Printed Name Title NOTARIZED: Sworn to and subscribed before me this day of 20. (Notary Public) Abortion or Reproductive Health Center Page 8

9 MANDATORY ACKNOWLEDGMENT NOTICE Pursuant to Alabama Code section , every applicant seeking from a state agency a license, certificate, permit, or authorization to engage in a profession, occupation, or commercial activity, must provide the social security number of the person signing the application, whether as an individual or on behalf of an entity or corporation. Failure to provide this social security number will result in the denial of the application. Print or Type Name of Person Signing Application: Social Security Number of Person Signing Application: Print or Type the Facility Name: THIS PAGE IS NOT PUBLIC RECORD Abortion or Reproductive Health Center Page 9

Pre-License Filing *NOTICE * THIS FORM WAS REVISED IN OCTOBER 2013 PLEASE READ CAREFULLY - THIS FILING IS REQUIRED FOR ALL HEALTHCARE FACILITIES THAT MUST SUBMIT TO ARCHITECTURAL REVIEW AND MUST BE SUBMITTED

11 F0091 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE Post Office Box 136, Jackson, MS 39205-0136 (601)359-9055 Application for Registration or Renewal of Athlete Agent A Certificate of Registration or

APPLICATION FOR LICENSURE AS AN INSTALLMENT SELLER PART 1 The Pennsylvania Department of Banking and Securities (the Department) welcomes your request for this Installment Seller application. It is the

Company New Application Checklist Agency Requirements NH This document includes instructions to apply for an application for a Motor Vehicle Sales Finance company (principal/headquarter location) license.

FBN Requirements (SB 1467) Effective January 1, 2015, pursuant to Senate Bill 1467, the Los Angeles County Registrar/Recorder County Clerk s Office will require a Notarized Affidavit of Identity form to

Form 503 General Information (Assumed Name Certificate) The attached form is drafted to meet minimal statutory filing requirements pursuant to the relevant code provisions. This form and the information

STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A LICENSE UNDER THE CALIFORNIA FINANCE LENDERS LAW (CFLL) WHO IS REQUIRED TO OBTAIN A FINANCE LENDERS

INSTRUCTIONS FOR COMPLETING DBPR ABT 6021 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR PASSENGER VESSEL PERMIT If you have any questions or need assistance in completing this application,

JUS 8771 (Rev. 12/2011) PAGE 1 OF 9 Instructions for Completing the Seller of Travel Registration Application If you need more space to answer a question, you may attach additional pages marked with the

HOW TO OBTAIN A NEW CONTRACTOR LICENSE These instructions apply to new licenses only. If you wish to add a classification or a qualifying party to an existing license, please see HOW TO ADD A CLASSIFICATION

State of Nevada Department of Business and Industry Division of Industrial Relations WORKERS COMPENSATION SECTION Employee Leasing Company (PEO) Registration Application Completion of this Registration

Proper Procedures to Make Business Permit Changes Board approval to make changes to a business permit depends upon: A properly completed Application to Make Business Permit Changes accompanied by the appropriate

INSTRUCTIONS FOR COMPLETING DBPR ABT 6006 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR CIGAR WHOLESALE DEALER PERMIT If you have any questions or need assistance in completing this application,

FBN Requirements (SB 1467) Effective January 1, 2015, pursuant to Senate Bill 1467, the Los Angeles County Registrar/Recorder County Clerk s Office will require a Notarized Affidavit of Identity form to

Attach a clear, full-face passportstyle photograph (2 x 2 ) of your head and shoulders, taken within the past six months. A photo is required with each application. Do not use a paper clip to attach the

APPLICATION FOR LICENSE TO OPERATE ALARM BUSINESS AS DEFINED BY CHAPTER 720, ST. LOUIS COUNTY REVISED ORDINANCES 1. of Applicant (Corporation if a Corporation, Parent Corporation if Different from Subsidiary,

MAINE BOARD OF PHARMACY Application information to assist in completing your application. This information is not designed to include all information on laws and rules and it is strongly recommended that

Maryland Insurance Administration Individual Producer License Renewal / Reinstatement Checklist Important Update: The attached application and supplement may be used to renew or reinstate an existing Maryland

INSTRUCTION SHEET In order for your application to be processed, ALL REQUIRED SUPPORTING DOCUMENTATION MUST BE SUBMITTED with the application and required fee unless otherwise directed in the instructions.

State of Alaska Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Board of Registration for Architects, Engineers and Land Surveyors

INSTRUCTIONS APPLICATION FOR HOME MEDICAL EQUIPMENT PROVIDER Purpose Completing the Application The application which you submit is valid for 3 years from date of receipt. The Home Medical Equipment and

DEPARTMENT OF HEALTH BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING APPLICATION FOR LIMITED LICENSURE and Instructions APPLICATION FOR LIMITED LICENSURE INSTRUCTIONS

CITY OF ST. MARYS, GEORGIA 418 Osborne Street St. Marys, GA 31558 (912) 510-4039 ITEMS TO BE SUBMITTED WITH THE APPLICATION FOR A NEW ALCOHOL LICENSE (1) Complete and accurate application form. NOTE: Incomplete

INSTRUCTIONS 1. This application must be typed or printed legibly and completed in its entirety. 2. This application and all supporting material must be submitted with the appropriate application fee as

Form 204 General Information (Certificate of Formation Professional Association) The attached form is drafted to meet minimal statutory filing requirements pursuant to the relevant code provisions. This

INFORMATION FOR APPLYING FOR A USED MOTOR VEHICLE DEALERS LICENSE The Used Motor Vehicle Division meets six times per year. Please refer to the board meeting schedule on the internet. The website is www.sos.ga.gov/plb/usedcar.

Athletic Trainer License Application Methods Please read carefully to determine the application method for which you are qualified Indicate the appropriate method on the application and submit the required

THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of the Professions, State Board for Engineering and Land Surveying PHONE: 518-474-3817 ext. 140 FAX: 518-473-6282

State of Florida Department of Business and Professional Regulation Board of Accountancy Application for CPA Firm Form # DBPR CPA 4 1 of 6 APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist

SOUTH CAROLINA DEPARTMENT OF TRANSPORTATION Policies and Procedures for PREQUALIFICATION of PRIME CONTRACTORS Rev. July 1, 2014 Replaces Previous Versions This policy and procedure document is a working

Division of Commercial Licensing and REQUIREMENTS/APPLICATION FOR REAL ESTATE SALESPERSONS The following Requirements apply to Rhode Island Residents and Non-residents. Candidates of legal age (18 years

Form 2501 General Information (Application for Registration as an Athlete Agent) The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant code provisions. This

STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST APPLICATION INSTRUCTIONS AND INFORMATION General Statement:

PRIVATE PROVIDER REQUIREMENTS General Information and Checklist Rev. 10-01-2014 The use of Private Providers is authorized by Florida Statute 553.791 (Alternative Plans Review and Inspection). The City

ALABAMA ELECTRONIC SECURITY BOARD OF LICENSURE ADMINISTRATIVE CODE 304-X-1-.01 Definitions (1) Administrative Fee: A fee is charged to first time applicants, or those reapplying as first time applicants,

STATE OF NEW YORK > DEPARTMENT OF LABOR DIVISION OF SAFETY AND HEALTH LICENSE AND CERTIFICATE UNIT BUILDING 12, ROOM 161 STATE CAMPUS ALBANY, NY 12240 (518) 457>2735 GENERAL INFORMATION INFORMATION FOR

LOUISIANA DEPARTMENT OF INSURANCE JAMES J. DONELON COMMISSIONER INSTRUCTIONS FOR ANNUAL REPORT FOR A VIATICAL SETTLEMENT BROKER IN THE STATE OF LOUISIANA GENERAL INSTRUCTIONS This packet is designed to

Form 203 General Information (Certificate of Formation Professional Corporation) The attached form is drafted to meet minimal statutory filing requirements pursuant to the relevant code provisions. This

License Application for a Life Settlement Provider or Broker The Life Settlement Provider s and Broker s application requires four (4) categories of information: Section I Application Form and Fee Section

INSTRUCTION SHEET BARBER SCHOOL BEFORE COMPLETING THE APPLICATION PACKAGE, read each of the steps below in the order that they are listed, then follow the directions for the specific type of application

State of Florida Department of Business and Professional Regulation Construction Industry Licensing Board Application for Certified Pollutant Storage Systems Contractor as an Individual Form # DBPR CILB

I. INSTRUCTIONS NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Location: 400 EAST TRYON ROAD RALEIGH NC 27610 (919) 779-0700 abc.nc.gov MAIL TO ADDRESS ON BACK OF FORM HOW TO APPLY FOR AN ABC RETAIL

Form 401 General Information (Change of Registered Agent/Office) The attached form is drafted to meet minimal statutory filing requirements pursuant to the relevant code provisions. This form and the information

State of New Jersey Department of Labor and Workforce Development Division of Wage and Hour Compliance PO Box 389 Trenton, New Jersey 08625-0389 Instructions for Completing the Application for Public Works

STATE OF MINNESOTA DEPARTMENT OF COMMERCE DIVISION OF FINANCIAL INSTITUTIONS RE: CONSUMER SMALL LOAN LENDER ACT Application may be made on the attached forms for a Consumer Small Loan Lending license pursuant